Health and non-health benefits and equity impacts of individual-level economic relief programs during epidemics/pandemics in high income settings: a scoping review

Background Economic relief programs are strategies designed to sustain societal welfare and population health during a regional or global scale infectious disease outbreak. While economic relief programmes are considered essential during a regional or global health crisis, there is no clear consensus in the literature about their health and non-health benefits and their impact on promoting equity. Methods We conducted a scoping review, searching eight electronic databases from January 01, 2001, to April 3, 2023, using text words and subject headings for recent pathogens (coronavirus (COVID-19), Ebola, Influenza, Middle East Respiratory Syndrome (MERS), severe acute respiratory syndrome (SARS), HIV, West Nile, and Zika), and economic relief programs; but restricted eligibility to high-income countries and selected diseases due to volume. Title and abstract screening were conducted by trained reviewers and Distiller AI software. Data were extracted in duplicates by two trained reviewers using a pretested form, and key findings were charted using a narrative approach. Results We identified 27,263 de-duplicated records, of which 50 were eligible. Included studies were on COVID-19 and Influenza, published between 2014 and 2023. Zero eligible studies were on MERS, SARS, Zika, Ebola, or West Nile Virus. We identified seven program types of which cash transfer (n = 12) and vaccination or testing incentive (n = 9) were most common. Individual-level economic relief programs were reported to have varying degrees of impact on public health measures, and sometimes affected population health outcomes. Expanding paid sick leave programs had the highest number of studies reporting health-related outcomes and positively impacted public health measures (isolation, vaccination uptake) and health outcomes (case counts and the utilization of healthcare services). Equity impact was most often reported for cash transfer programs and incentive for vaccination programs. Positive effects on general well-being and non-health outcomes included improved mental well-being and quality of life, food security, financial resilience, and job security. Conclusions Our findings suggest that individual-level economic relief programs can have significant impacts on public health measures, population health outcomes and equity. As countries prepare for future pandemics, our findings provide evidence to stakeholders to recognize health equity as a fundamental public health goal when designing pandemic preparedness policies. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-19493-8.

our findings provide evidence to stakeholders to recognize health equity as a fundamental public health goal when designing pandemic preparedness policies.

Background
Infectious disease epidemics and pandemics can result in catastrophic economic collapse and disastrous human, social, and health consequences [1].Populations experiencing social and economic marginalization have consistently experienced the highest risk of infection, disease severity and death [2][3][4].Across high-income settings, racially minoritized individuals experienced disproportionate burden of COVID-19, H1N1 influenza, and tuberculosis [3,5,6]; driven by how systemic racism has shaped occupational risks, housing, and health care [6].
Individual-level economic relief programs are economic interventions implemented by governments, institutions, or private sources during an epidemic or pandemic to limit the disproportional health and economic consequences often experienced by populations at higher risk of the disease (e.g., low-and modest-income families, families with children, homeless population, and indigenous persons), support public measures and improve population health [7].Programs implemented during the COVID-19 pandemic included paid sick leave, caregiver and childcare benefits, unemployment compensations for furloughed workers, and food supply and direct cash payments to low-income earners [7].
Pandemic-informed individual level economic relief policies are intended to encourage changes in human behaviour and motivate individuals to make healthy choices that impact health and overall well-being [8][9][10].In a 2020 survey, 94% of respondents indicated compliance to a proposed two-week self -quarantine during the COVID-19 outbreak if financial compensation for lost wages is guaranteed; however, when the financial compensation option was removed, the compliance rate dropped to 57% [9].Nevertheless, we found very limited evidence on the health-related benefits of individual level economic relief programs in our exploratory review, conducted in few electronic databases in September 2020 to assess the feasibility of a broader review.
Because the implementation individual level economic relief programs are often costly [7] and there is often a debate about their impact during outbreaks [11], we systematically chart their health and non-health benefits, and equity impacts to inform pandemic preparedness planning.
Our objective is to map the current state of the literature on individual-level economic relief programs during infectious disease outbreaks and their impact on the effectiveness of public health measures, individual and population health, non-health outcomes, and health equity during regional or global scale infectious disease outbreaks.Our review questions are: 1. What are the types of individual-level economic relief programs implemented during an infectious disease outbreak?2. How and to what extent do pandemic/epidemic individual-level economic relief programs impact the effectiveness of public health measures during epidemics?3. How and to what extent do changes in public health measures associated with pandemic/epidemic individual-level economic relief programs impact health outcomes?4. Do health benefits associated with pandemic/epidemic individual-level economic relief programs differ across demographic and social groups, and place of residence?If so, how? 5. What are the non-health outcomes assessed in eligible studies identified? 6.What are the limitations associated with pandemic/ epidemic individual-level economic relief programs?7. What are the knowledge gaps in the literature in relation to the questions above?

Methods
We followed the updated Arksey and O'Malley's framework on conducting scoping review [12,13] and the Preferred Reporting Items in Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guideline [14].
Our protocol is available at https:// doi.org/ 10. 1136/ bmjop en-2021-057386 [15].We made the following changes to the protocol: We excluded HIV publications, publications from low-and middle-income countries, and non-English publications due to their volume, constrained resources, and differences in health systems structure.Also, jurisdictional differences in the health benefits associated with pandemic/epidemic individuallevel economic relief programmes were assessed by place of residence (e.g., urban or rural), not by country type.

Search strategy
An information specialist developed our comprehensive search strategy using text words and Medical Subject Headings (MeSH) terms.In the original search strategy, from January 1, 2001, to October 8, 2021, we searched concepts relating to pandemic/epidemic infectious diseases (specifically, coronaviruses, influenza A, SARS, MERS, HIV/AIDS, Zika, Ebola and West Nile) and economic relief programs (e.g., government financing, public assistance, food assistance, medical assistance, workers compensation, social welfare, charities, and childcare).We restricted our search to post-2001 because of the global changes observed in living standards and health care delivery (now focused on primary health care) since countries implemented the Millennium Development Goals in 2001 [16].We updated our search on April 3, 2023.For the updated search, we excluded HIV terms from the search strategy due to the volume of HIV/AIDS publications during the original screening.The original search strategy was developed in the Ovid Medline and then translated to other databases.Both MEDLINE search strategies are reported in the appendix.
We searched eight databases-MEDLINE, OVID E-pub Ahead of Print In-Process & Other Non-Indexed Citations, EMBASE, Cochrane CENTRAL, all on the OvidSP platform; EconLit, CINAHL, on the EBSCO platform; ISI Web of Science on the Clarivate platform, and Global Index Medicus from the World Health Organization (WHO).We manually searched the reference lists of eligible studies to ensure we do not miss relevant articles.
Our search excluded clinical conferences, comments, editorials, letters, and animal studies.No study design, language or country restriction was employed in our search strategy.

Study screening and data extraction
De-duplication, and title and abstract screening were conducted using the Distiller SR software, including the artificial intelligence (AI) simulation tool that automates the title and abstract screening process [17].Four trained reviewers conducted the title and abstract screening in parallel without using Distiller AI.Distiller AI was used at the end of the screening process to check for screening errors among excluded records.Retrieved records were tagged by country type (high-income or low-and-middleincome) and disease (HIV, COVID-19, Zika, Ebola, West Nile, MERS, SARS, or influenza A (H1N1 and H2N2).We excluded commentaries, book chapters, conference abstracts with no full text, study protocols, and business targeted economic relief programs.
Following title and abstract screening, we restricted study eligibility to COVID-19, Zika, Ebola, West Nile, MERS, SARS, or influenza A (H1N1 and H2N2) and high-income settings due to volume (see Fig. 1 for details on the excluded studies).We also excluded non-English articles due to limited translation resources.
Full text screening and data extraction were conducted in duplicates by two trained reviewers using Microsoft Excel software.Disagreements were resolved through discussions until consensus was reached.Data abstraction was conducted using a pre-tested template.Data elements included study and population characteristics (study objective, study design, study population), infectious disease outbreak description (name of outbreak and time of outbreak), economic relief program description (eligible population, program and equity considerations used in assessing eligibility and program implementation time period), public health measure outcomes, population health outcomes, general health outcomes, equity impacts (by variables such as demographics, social and jurisdiction), and non-health outcomes.
Equity-impact of a disease and implemented interventions are often measured among groups or settings that are likely to be disadvantaged by the outbreak [5].Factors that may be considered when measuring inequities include income, employment, and gender [5].In our review, data extraction and synthesis on equity impact was guided by the PROGRESS-Plus framework to ensure that we systematically consider health equity under relevant dimensions, including demography, social factors, disability, and sexual orientation [18].
Individual level economic relief programs were categorized by the nature of the program and intended population.For examples, monetary incentive programs directed to increase vaccine uptake or testing were categorized as "incentive for vaccination or testing" program; fiscal stimulus directed to workers when ill/exposed to encourage quarantine/isolation was termed "expanded paid sick leave"; employment insurance payment to furloughed workers or unemployed individuals was termed "unemployed assistance"; direct cash payment to support individuals and households was termed "cash transfer" food supply programs to communities, schools, households was categorized as "food assistance"; two or more individual-level economic relief program groups simultaneously was termed "mixed program" and "others" program category which included subsidy program and expanded child tax credit program.
Full details of the data elements extracted is described in our protocol [13].

Data charting
We summarized public health measures, health, nonhealth measures and equity impact associated with individual-level economic programs using a narrative approach and visual plots.In the equity-impact analysis, we provided details on how outcomes differed by equity variables.

Results
Our initial and updated search yielded 27,263 deduplicated records from the eight databases.After title and abstract screening, we retrieved 415 records for full-text screening.Following the amended eligibility criteria, we excluded 227 studies from low-and middle-income countries and 45 studies on HIV from high-income countries.We assessed the full text of 143 studies and excluded 93 records.The reasons for exclusions included: no quantitative assessment of the individual-level economic relief program (n = 33), not an individual-level economic relief program (n = 23), and book/commentary/report/opinion/ research letters/ conference abstract/media release (n = 25).Fifty studies were found eligible for final review.The PRISMA flow diagram is shown in Fig. 1.
Three studies, reporting on programs of expanded paid sick leave (n = 1), domestic travel subsidy (n = 1), and cash transfer (n = 1), found that economic relief programs could have a positive, neutral, or negative impact on social distancing, depending on program type [42,56,61].In two studies, expanded paid sick leave was associated with an increased probability of workers isolating when sick by 15% [28] and an increased amount of time spent away from work when sick by 1.10 days [38].Expanding paid sick leave was linked to an increase in vaccination rates during influenza disease outbreaks by 10-15% [37,39].Vaccine incentives were reported to significantly increase vaccination rates by 7%-23.2%[32,40,65] in the context of COVID-19 and influenza outbreaks.A domestic travel subsidy program had no impact on masking practice, respiratory hygiene practice & surface disinfection [56].
Population health outcomes based on programs' impact on public health measures were evaluated by eight studies [32,39,41,42,56,58,61].Health outcomes reported on included symptom and case counts, infection transmission, healthcare visits and herd immunity.Herd immunity was measured by a multinomial model regressing the effect COVID-19 vaccine incentive on US population vaccination level.[32] The economic relief programs were cash transfers [61], expanded paid sick leave [19,38,39,42], incentives for vaccination/testing [32,58], and domestic travel subsidy [56].Expanded paid sick leave and incentive for vaccination/testing were associated with positive health outcomes [19,32,38,39,42,58] while cash transfer and domestic travel subsidy were linked to neutral [61] and negative health outcomes [56] respectively.
Health outcomes associated with cash transfer programs differed across demographic factors (race and age) in two studies [48,61].Cash transfer was association with reduced incidence of COVID-19 symptoms among 50 years or older [48] and improved financial savings (a proxy for improved mental health) among Hispanics [61].
In three studies assessing the effect of incentive for vaccination, health outcomes significantly differed by race, age, and employment [32,45,65].Vaccine incentive increased vaccination rates among Blacks and non-working elderly in COVID-19 pandemic and influenza epidemic [32,65].Vaccine incentive reduced vaccine uptake among 40 years and older in a COVID-19 study [45].
Expanded child tax credit program was linked to reduced anxiety symptoms among Blacks and Hispanics [44].Domestic travel subsidy was associated with an increase in the incidence of COVID-19 symptoms among young participants [56].Table 1 presents the health, equity impact and non-health outcomes reported in eligible studies.

Limitations associated with individual-level economic relief programs
Three studies discussed the limitations of their respective programs [21,30,57].Limitations associated with unemployment assistance programs in two studies included state-level variability in unemployment insurance benefits [21], the complexity of the unemployment insurance program structure, the presence of barriers that prevent eligible individuals from receiving program benefits [21], and issues related to eligibility and implementation challenges, such as erroneous data on unemployment rate [30].In a COVID-19 cash transfer program study, the authors suggested that the implemented consumption voucher program could constrain consumer choice and possibly harm consumer welfare and economic efficiency in the long run because beneficiaries could only redeem the vouchers at small business stores [57].

Knowledge gap
Our review identified four key knowledge gaps: Limited disease focus.All eligible studies were on COVID-19 and influenza.Despite the occurrence of SARS, H1N1 influenza, MERS, Ebola, Zika and West Nile Virus outbreaks during eligibility period, we did not identify any eligible study on these outbreaks in our review.
Lack of evidence on the effect of unemployment assistance programs and food assistance programs on public health measures (such as physical distancing, quarantine/ isolation, vaccination).Among the unemployment assistance programs and food assistance programs studies included in our review, none reported on public health measure impact.
Limited evidence of the impact of individual-level economic relief programs on equityOnly 16% of eligible studies reported on the equity impact.None of the eight studies that assessed the equity impact of unemployment assistance programs, vaccine incentive programs, "other" programs, and cash transfer programs reported the program's effect on relevant equity variables.The impact of expanded paid sick leave programs and food assistance programs on equity remains undetermined.
Lack of evidence on the long-term effect of individuallevel economic relief programs on health outcomes, which were not considered in the 36 eligible studies that reported health outcomes.Assessing the long-term health effects of individual-level economic relief policies, particularly post-pandemic during the recovery stage, could provide insight into the importance of the programs to equity and societal well-being.

Discussion
Our review charts the current state of the literature on the types of individual-level economic relief programs implemented during infectious disease outbreaks.
Expanded paid sick leave was found to have a consistent pattern of improved health outcomes.Our findings corroborate the findings of a recent meta-analysis study of 12 studies, reporting that paid sick leave was associated with increased odds of following public health directives (vaccine uptake) and seeking medical care [73].
Individual-level economic relief programs improved population health outcomes among equity-deserving populations.The improved health outcomes observed among equity seeking populations is likely due to their improved adherence to public health measures enabled by economic relief programs.[74].
Furthermore, most individual-level economic relief program types positively impacted mental health, reaffirming the long-established evidence of the relationship between financial well-being and psychological well-being [72,75].Non-health outcomes associated with the programs had beneficial impact on key domains of social determinants of health i.e., economic stability and healthcare access and quality.Addressing social determinants of health is fundamental for improving health and reducing longstanding inequities in societal health [76].
Lastly, we identified four knowledge gaps which could help in priority setting of future research.Tailoring future research to address gaps would provide a more wholistic view to the robust and comprehensive impact of individual-level economic relief programs on health and equity during pre-and post-pandemic periods.
Our review has some limitations.First, we restricted our search strategy to studies in high-income countries due to the high volume of studies.Future reviews should synthesize the impact of similar programs in low-and middle-income countries.Second, due to the volume of studies identified we were only able to focus on selected infectious diseases.This limitation makes our findings disease-specific, requiring careful interpretation if attempting to extrapolate findings to other infectious diseases (e.g., HIV).Further, we did not search the grey literature and only included publications in English.Our findings may therefore be biased towards English-speaking high-income settings.Our review's strength lies in our use of a rigorous scoping review methodology.Screening and data extraction forms were pretested by all reviewers and revised as needed to ensure they are adequately sensitive to capture outcomes in eligible studies.We searched multiple relevant electronic scientific databases to ensure our results were comprehensive and accurate.Lastly, our eligibility criteria had no restriction on study design.

Policy implications
Our findings provide compelling evidence that shows that individual-level economic relief programs are valuable, and their importance transcends health in pandemics.Although individual-level economic relief programs are capital-intensive, their broad and positive impact on public health measures, population health, general wellbeing, equity, and social determinants of health (e.g., economic stability) may make investing in them worthwhile.
As countries prepare for future pandemics, our findings provide evidence to stakeholders to recognize health equity as a fundamental public health goal when designing pandemic preparedness policies.Further, expansion of well-designed, robust, social safety net programs (such as individual level economic relief programs) for equity-deserving populations should be considered since evidence show that these programs not only improve health equity and social needs, but they may also address social determinants of heath.

Conclusion
Individual-level economic relief programs implemented during epidemics/pandemics significantly impacted public health measures, outbreak-related population health outcomes and health equity.Our study findings can help inform investment decisions on individual-level economic relief programs to protect population health in future pandemics, particularly for equity-seeking populations, to prevent the widening of pre-existing societal inequity.

Fig. 1
Fig. 1 Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) flowchart

Fig. 2
Fig. 2 Heat map depicting program and studies characteristics of included studies.Footnotes: [The number of studies by individual-level economic relief program type and country are ordered from highest to lowest (left to right).We assigned dark to light colours to depict a no study scenario to having more than 6 studies scenarios]

Fig. 3
Fig. 3 Coxcomb Chart depicting study outcomes by individual-level economic relief program type Footnotes: [The different colours of the ray indicate the various components of the review outcomes.The width of the ray indicates the impact of the individual-level economic relief program type on the components of the review outcomes.A wide width implies that the individual-level economic relief program type has a positive impact on the specific review outcome assessed and a narrow width denotes a negative impact.]

Table 1
Summary of the health and non-health outcomes, and equity-impact reported in included studies